1. Healthy People
    Provides science-based, national goals and objectives with 10-year targets designed to guide national health promotion and disease prevention efforts to improve the health of all people in the United States
  2. Preconception Health Objectives
    • Increase the proportion of women delivering a live birth who received preconception care services and practiced key recommended preconception health behaviors
    • Increase the proportion of women of childbearing potential with intake of at least 400 μg of folic acid from fortified foods or dietary supplements
    • Reduce the proportion of women of childbearing potential who have low red blood cell folate concentrations
    • Reduce the proportion of persons aged 18 to 44 years who have impaired fecundity 
  3. Ovary
    • One of a pair of primary reproductive organs in which oocytes form and mature
    • Produces hormones estrogen and progesterone which stimulate maturation of oocyte
    • Formation of corpus luteum
    • Preparation of the uterine lining for pregnancy
  4. Uterus
    • Chamber in which embryo develops
    • Secretes mucus that helps sperm move into it and bars many bacteria
  5. Myometrium
    Thick muscle layers of uterus that stretch enormously during pregnancy
  6. Endomedtrium
    • Inner lining of uterus
    • Site of implantation of blastocyst (early embryonic stage) becomes thickened, nutrient-packed, highly vascularized tissue during a pregnancy
    • Gives rise to maternal portion of placenta
  7. Testis
    • One of a pair of primary reproductive organs
    • Packed with sperm-producing tubules and cells that secrete testosterone and other hormones
  8. Seminal Vesicle
    One of a pair of glands that secrete fructose and prostaglandins which become part of the semen
  9. Epididymis
    • One of a pair of ducts in which sperm complete maturation
    • The portion farthest from testis stores mature sperm
  10. Gonadotropin-Releasing Hormone
    • Source: hypothalamus
    • Stimulates release of FSH and LH
  11. Follice-Stimulating Hormone
    • Source: pituitary gland
    • Stimulates the maturation of ova and sperm
  12. Luteinizing Hormone
    • Source: pituitary gland
    • Stimulates secretion of estrogen, progesterone, and testosterone and growth of the corpus luteum
  13. Estrogen
    • Source: ovaries, testes, fat cells, corpus luteum, and placenta
    • Stimulates release of GnRH in follicular plase and inhibits in luteal phase
    • Stimulates thickening of uterine wall during menstrual cycle
  14. Progesterone
    • Source: ovaries and placenta
    • Prepares uterus for fertilized ovum and to maintain a pregnancy
    • Stimulates uterine lining buildup during menstrual cycle
    • Helps stimulate cell division of fertilized ova
    • Inhibits action of testosterone
  15. Testosterone
    • Source: testes
    • Stimulates maturation of male sex organs and sperm, formation of muscle tissue and other functions
  16. Ovulation
    • LH and FSH increase during this time
    • Estradiol decreases 
  17. Infertility
    • The lack of conception after one year of unprotected intercourse
    • 40% of couples diagnosed with this will conceive a child within 3 years without technology
  18. Luteal Phase
    Corpus luteum secretes progesterone to help with the potential of a fertile egg and prepares body for pregnancy
  19. Infertility: Male & Female Factors
    • Weight loss >15%
    • Inadequate body fat
    • Extreme levels of exercise
    • High alcohol intake
    • Endocrine disorders
    • Celiac disease
    • Severe stress
    • Diabetes
  20. Infertility: Female Factors
    • Recent oral contraceptive use
    • Anorexia or bulemia
    • High caffeine intake
    • High fiber intake
    • Age >35 years
    • Pelvic inflammatory disease
    • Endometriosis
  21. Infertility: Male Factors
    • Inadequate zinc status
    • Heavy metal exposure
    • Halogen and glycol exposure
    • Estrogen exposure
    • Sperm defects
    • Excessive heat to testes
    • Steroid abuse
  22. Fertility: Nutrition
    • Acute undernutrition is associated with a dramatic decline in fertility
    • Weight loss >10-15% of usual weight decreases estrogen, results in amenorrhea
    • Decreased fertility is seen with low or high body fat
  23. Amenorrhea
    The lack of a menstural cycle
  24. Fertility: Contraceptives
    • Implants, patches and injections are used and carry a slight risk for thromboembolism
    • Oral contraceptives, combinations of estrogen and progesterone may increase serum TG, TC, and HDL, decrease serum B-12 and increase serum copper
    • Injections and patches have reported weight gain as an adverse effect
  25. Oral Contraceptives
    • Increased blood levels of HDL cholesterol
    • Increased blood levels of triglycerides and LDL cholesterol
    • Increased risk of venous thromboembolism, cervical cancer, and cardiovascular disease
    • Decreased blood levels of vitamins B12 & B6
    • Increased blood lvels of copper
  26. Contraceptive Injections
    • Weight gain
    • Increased blood levels of LDL cholesterol and insulsin
    • Decreased blood levels of HDL cholesterol
    • Decreased bone density
  27. Contraceptive Implants
    Weight gain
  28. Folate Status
    • Neural tube closes within the first few weeks of pregnancy
    • Need to get women this before they know they’re pregnant
    • -Needed to prevent neural tube defects
  29. Preconceptual Nutrition Concerns
    • Too much vitamin A before pregnancy is bad
    • Iron deficient results in poor pregnancy outcome
    • Lead exposure
  30. WIC
    • Provide nutritional counseling
    • Have to have a nutritional risk to participate
    • Funded by the USDA
    • Target low-income, nutritionally at-risk populations with supplemental foods and nutrition education
    • Pregnant, breastfeeding, and non-breastfeeding, postpartum
    • women, infants and children up to 5 years of age
  31. Sprinkles
    • Developed to prevent and treat micronutrient deficiencies among young children and other vulnerable groups at risk
    • Sachets (like small packets of sugar) containing a blend of micronutrients in powder form
    • Coating of the iron prevents changes to the taste, color or texture of the food to which they are added
    • Used to fortify foods that lower income families consume
  32. CDC's Preconception Health Initiative
    • Published a report highlighting recommendations for improving preconception health
    • Preconception health care should be delivered at regular primary care visits
    • Focus of care should be on vaccinations, weight, iron and folate status, assessment of alcohol use and management of disorders such as diabetes
  33. Take folic acid
    Continue to eat healthy and maintain proper 
    Stop taking oral contraceptive pills
    You are an RD and your patient is a 22 year old college student.  She is healthy, takes oral contraceptives, and is interested in becoming pregnant in the next couple of years. She takes no supplements, but says she eats healthy. What are the key nutrition recommendations you would discuss with her?
  34. Premenstrual Syndrome
    A condition occurring among women of reproductive age that includes a group of physical, psychological, and behavioral symptoms with the onset of the luteal phase and subsiding with menstrual bleeding
  35. Premenstrual Dysphoric Disorder
    Severe form of PMS with mood swings, depressed mood, irritability, anxiety, and physical symptoms
  36. Physical Signs of PMS
    • Fatigue
    • Bloating
    • Swelling of hands of feet
    • Headache
    • Tender breasts
    • Nausea
  37. Psychological Symptoms of PMS
    • Craving of sweet or salty foods
    • Depression
    • Irritability
    • Mood swings 
    • Anxiety
    • Social withdrawal
  38. PMS: Vitamin D & Calcium
    • A high total vitamin D (700 IU) intake had a relative risk of 0.59 for PMS symptoms compared to those in the lowest quintile (100 IU)
    • Those with a high intake of dietary calcium (1200 mg) had a relative risk of 0.7 for PMS symptoms compared to those with a low intake (500 mg)
  39. PDD Medical Management
    • Use selective serotonin-reuptake inhibitors
    • GnRH agonist-reduce the release of FSH and LH, prevent ovulation and result in decreased estrogen levels
    • Both significantly reduce symptoms
  40. Hypothalamic Amenorrhea
    • Energy deficits disrupts the release of GnRH and LH and leads to anovulation and loss of menstrual cycles
    • Related to underweight, weight loss or weight loss accompanied by intense exercise
  41. Original Female Athlete Triad
    • Disordered eating
    • Amennorhea
    • Osteoporosis
    • Gymnastics is an activity which places high strains on the skeleton, however adolescent gymnasts have been investigated as having a risk for premature bone loss
    • Gymnasts, by nature of the sport, strive for a lean body type
  42. Female Athlete Triad
    • Energy availability: optimal vs low
    • Menstrual function: amenorrhea vs eumenorrhea
    • Bone mineral density: osteoporosis vs optimal bone health
  43. Eating Disorders
    • One symptom of anorexia is amenorrhea; this is manifested by irregular release of GnRH and low levels of estrogen
    • Losing 15% of body mass
    • Weight gain can bring the menstrual period back and increase fertility
  44. Fertility: Obesity
    • Sex hormone binding globulin (SHBG)- levels are decreased
    • -Transfers estrogen and testosterone
    • -Availability of sex hormones depends on the level of SHBG
    • Hyperandrogenism in some women and reduced androgens in men
    • Central body fat (waist circumference > 38 inches) increases risk for infertility
    • Weight loss significantly increases fertility
    • Have low vitamin D levels
    • Increased chance for gestational diabetes and preeclampsia
    • Need less weight gain
    • Post-partum weight gain is a leading cause
  45. Polycystic Ovarian Syndrome
    • The most common endocrine disorder in women of reproductive age (10% of women)
    • Leading cause of infertility
    • Strong genetic component that interacts with environmental factors (e.g., insulin resistance)
  46. Polycystic Ovarian Syndrome
    • The ovary does not make the hormones it needs for an egg to fully mature
    • Since no egg is released, ovulation does not occur and progesterone is not made (i.e., a woman's menstrual cycle becomes irregular/absent)
    • The cysts produce male hormones, which also prevent ovulation
  47. PCOS: Clinical Signs
    • Menstrual irregularities
    • Common signs are low HDL and high triglycerides
    • Induces metabolic issues
    • Major signs: insulin resistance and high testosterone
    • -Treat insulin resistance first
    • -If you can improve insulin sensitivity, you don’t have to rely on medication
  48. PCOS: Treatment
    • Based on symptoms, and lowering chances of heart disease and diabetes
    • Many women will need a combination of treatments to meet these goals:
    • -Birth Control Pills
    • -Diabetes Medications
    • -Fertility Medications (to stimulate ovulation)
    • -Surgery
    • -Lifestyle Modifications
  49. Pregnancy: Type II Diabetes
    • Exercise can increase insulin sensitivity in type II diabetes
    • Begin moderate exercise program before pregnancy and continue low-impact activities throughout
    • Key is to control blood glucose levels
    • Shouldn’t get pregnant until the woman has lost an adequate amount of weight
  50. Risks of Diabetes Mellitus
    • The baby being small, or growing too large and making delivery difficult for baby and mother
    • Increased risk of pre-eclampsia (high blood pressure and excess protein in the urine)
    • Increased risk of premature birth
    • Increased risk of the baby suffering respiratory distress syndrome when born
  51. PKU
    • Genetic defect
    • Lack the enzyme phenylalanine hydroxylase and cannot convert phenylalanine to tyrosine
    • Get build up of serum phenylalanine
  52. PKU Risks
    • Mental retardation
    • Heart defects
    • Low birth weight
    • Women maintaining normal phenylalanine levels can have healthy infants 
  53. Celiac Disease
    • Autoimmune disease in people with genetic susceptibility to protein gliadin found in gluten component of wheat, rye, barley, which causes malabsorption & flattening of intestinal lining
    • Linked to infertility in some women and men
  54. Management of Celiac Disease
    • Eliminate gluten in diet
    • Look for “gluten free” labels
    • Gluten found in many non-grain foods like hot dogs, deli meats, supplements, chips, bouillon, salad dressing, etc.
    • Correction of vitamin & mineral deficiencies
  55. Fetus
    • Depends on the mother's nutrient intake to meet its nutritional needs
    • Gets iron, calcium, vitamin D, and most importantly glucose from the mother
  56. Gravida
    The number of pregnancies a woman has experienced
  57. Parity
    • The number of previous deliveries a woman has experienced
    • Nulliparous
    • Primiparous
    • Multiparous
  58. Nulliparous
    No previous deliveries
  59. Primiparous
    One previous delivery
  60. Periconceptional
    • From conception: gestational age- 38 wks
    • From last menstrual period: menstrual age- 40 wks
  61. 1st Trimester
    • Weeks 0-12
    • Embryo: weeks 0-8
    • Miscarriage: weeks 0-20
  62. 2nd Trimester
    • Weeks 12-27
    • Fetus: weeks 8-40
    • Fetal death/stillbirth: weeks 20-40 
  63. 3rd Trimester
    • Weeks 27-birth
    • Very pre-term: <34 weeks
    • Pre-term: <37 weeks
    • Term: 38-42 weeks
    • Neonatal: <42 weeks
    • Postneonatal: 1 week after birth to months
  64. Perinatal
    • From 20 weeks gestational up to 1 month after birth
    • Death, generally from low birth weight and lack of nutrients
  65. Infant Mortality
    • Index of the population’s health status
    • Congenital malformations, low birthweight and sudden infant death syndrome are main causes
    • 1995- 7.6
    • 2006/2007- 6.8
  66. Maternal Physiology
    • Changes in maternal body composition & functions occur in specific sequence
    • Plasma volume is important to transfer all of the nutrients
    • -Also used to exchange gases and remove waste
    • Nutrient stores iron, calcium, fat
  67. Maternal Physiology Order
    • Plasma volume: week 20
    • Nutrient store: week 20
    • Placental weight: week 31
    • Uterine blood flow: week 37
    • Fetal weight: week 37
  68. Maternal Anabolic Changes
    • Takes place in the 1st half of pregnancy
    • Synthesizing
    • Blood volume expansion, increased cardiac output
    • Buildup of fat, nutrient, and liver glycogen stores
    • Growth of some maternal organs
    • Increased appetite, food intake
    • Decreased exercise tolerance
    • Increased levels of anabolic hormones
    • 10% of fetal growth
  69. Maternal Catabolic Changes
    • Takes place in the 2nd half of pregnancy
    • Releasing
    • Mobilization of fat and nutrient stores
    • Increased production and blood levels of glucose, triglycerides, and fatty acids
    • Decreased liver glycogen stores
    • Accelerated fasting metabolism
    • Increased levels of catabolic hormones
    • 90% of fetal growth
    • Heightened ability to deliver nutrients to fetus
  70. Human Chorionic Gonadortopin
    • Maintains early pregnancy by stimulating the corpus luteum to produce estrogen and progesterone
    • Stimulates the growth of the endometrium
    • Placenta produces estrogenand progesterone after the first 2 months of pregnancy
    • Increase around 10 weeks 
  71. Human Chorionic Somatotropin
    • Increases maternal isulin resistance to maintain glucose availability for fetal use
    • Promotes protein synthesis and the breakdown of fat for energy for maternal use
  72. Leptin
    May participate in the regulation of appetit and lipid metabolism, weight gain, and utilization of fat stores
  73. Carbohydrate Metabolism
    The fetus prefers glucose over fat as fuel and needs a constant supply in the 2nd half of pregnancy
  74. Carbohydrate Metabolism: Early Pregnancy
    High estrogen & progesterone stimulate insulin which increases glucose conversion to glycogen & fat
  75. Carbohydrate Metabolism: Late Pregnancy
    • Human chorionic somatotropin (hCS) and prolactin inhibit the conversion of glucose to glycogen and fat
    • “Diabetogenic effect of pregnancy:” insulin resistance increases
  76. Protein Metabolism
    • About 925 g of protein accumulate during gestation
    • Protein & amino acids are conserved
    • No evidence the body stores protein early in pregnancy
    • Needs must be met by mother’s intake of protein
  77. Fat Metabolism
    • Accumulate in first half of pregnancy
    • Enhanced fat mobilization in last half
    • Blood lipid levels increase
    • Increased cholesterol (LDL and HDL); substrate for steroid hormone synthesis
    • -High need of cholesterol for hormones
    • Increase in serum triglyceride levels (unrelated to diet)
    • -Occurs in prenatal state
  78. Calcium Metabolism
    • Increased bone turnover
    • The process of bone being resorbed or lost
    • Thinks mother stores some calcium for baby
  79. Sodium Metabolism
    • Accumulation in mother, placenta, & fetus
    • Restriction of it potentially harmful
  80. Pregnancy: Blood & Circulation
    • Blood volume increases 20%
    • Plasma volume increases 50%
    • Cardiac output increases 30-50%
    • -Goes up so you can get blood out to the increased tissues
    • Heart rate increases up to 6 BPM
    • Blood Pressure decreases 5-10 mmHg in the 1st half; then becomes normal during the 2nd half
  81. Pregnancy: Respiratory Changes
    • Increased tidal volume; i.e., amount of air inhaled and exhaled (30-40%)
    • Increased oxygen consumption (~ 10%)
  82. Pregnancy: Metabolic Adjustments
    • Increase in BMR 15-20%; related to increased oxygen consumption of uterine-placental-fetal tissue and the increased cardiac work of mother
    • Increase in fat utilization by the mother; to accommodate the high needs for glucose by the fetus (50 - 70%)
  83. Pregnancy: GI Changes
    • Relaxed GI muscle tone
    • Increased gastric and intestinal transit time
    • Majority of women experience heartburn, nausea, vomiting, and constipation
    • Some (1-2%) develop hyperemesis gravidarium- severe nausea and vomiting lasting throughout pregnancy
  84. Pregnancy: Kidney Changes
    • Increased glomerular filtration rate (50-60%)
    • Increased sodium conservation
    • Increased nutrient loss into urine
    • Increased risk of developing a UTI
  85. Glomerular Filtration Rate
    • What’s used to measure kidney function
    • The amount of blood that is being filtered by the kidneys on a rate basis
    • Has to increase during pregnancy to remove uria, nitrogen, and other wastes
  86. Pregnancy: Body Composition Changes
    • Body fat increases (~ 6 kg)
    • Fat-free mass increases, but not as much as fat mass
    • Body water increases
    • -Plasma
    • Overall, total body bone mineral does not change
    • Fat-free mass increases the energy expenditure
  87. Pregnancy: Bone Mass Density
    • There appears to be no net loss of bone during pregnancy; the calcium available to the fetus results primarily from enhanced calcium absorption
    • Preliminary research suggests women with usual intakes of <500 mg/day may experience a calcium loss during pregnancy
  88. Placenta
    • Organ that facilitates the exchange of nutrients and gases between the mother and fetus
    • Maximal growth occurs around week 31 of gestation
    • Makes up approximately 15% of the weight of the fetus
    • Requires its own delivery shortly after the baby is born
  89. Roles of Placenta
    • Separation of maternal and fetal blood
    • Nutrient transfer
    • Exchange of respiratory gases and waste products
    • Production of Hormones (hCG, estrogen, progesterone, others)
  90. Substances Transported through Placenta
    • Oxygen
    • Carbon dioxide
    • Fatty acids
    • Steroids
    • Nucleosides             
    • Electrolytes
    • Fat-soluble vitamins             
    • Sugars
    • Amino acids
    • Water-soluble vitamins*
    • Some cations
    • -(calcium, iron, iodine, phosphate)
  91. Passive Diffusion
    • Nutrients transferred from blood with higher concentration levels to blood with lower concentration levels
    • Water, some amino acids and glucose, free fatty acids, ketones, vitamins E and K, some minerals (Na, Cl), gases
  92. Facilitated Diffusion
    • Receptors on cell membranes increase the rate of nutrient transfer
    • Some glucose, vitamins A and D, iron
  93. Active Transport
    • Energy (from ATP) and cell membrane receptors
    • Water-soluble vitamins, some minerals (Ca, Zn, Fe, K), and amino acids
  94. Endocytosis
    • Nutrients and other molecules are engulfed by placenta membrane and released into fetal blood supply
    • Immunoglobulins, albumin
  95. Harmful Substances to Placenta
    Alcohol, excessive levels of vitamins, drugs, and certain viruses DO cross the placenta and get to the fetus
  96. Maternal Blood
    • Makes cholesterol
    • Receives progesterone and estrogen
  97. Placenta
    • Cannot make cholesterol
    • Can convert cholesterol to progesterone
    • Cannot convert progesterone to androgens
    • Can convert androgens to estrogens
  98. Fetus
    • Cannot convert cholesterol to progesterone
    • Can convert progesterone to androgens
  99. Fetal Growth Retardation 
    • Starts with maternal malnutrition
    • Then reduced blood volume expansion
    • Then inadequate increase in cardiac output
    • Then decreased placental blood flow
    • Then reduced placental size and reduced nutrient transfer
    • Leading to this..
  100. Differentiation
    Acquisition of one or more characteristics or functions different from the original cells
  101. Critical Period
    Preprogrammed time periods during which embryonic and fetal cells, organs and tissues are developed 
  102. Stages of Fetal Growth
    • Blastogenesis
    • Embryonic
    • Fetal stage
  103. Blastogenesis
    • Fertilized egg divides and the inner mass becomes the embryo and the outer mass becomes the trophoblast
    • The trophoblast becomes the placenta
  104. Embryonic Stage
    • Cells differentiate and become ectoderm (brain, nervous system), mesoderm (muscles, bone, CV and excretory systems) and endoderm (digestive system, respiratory and glandular)
    • By 60 days
  105. Fetal Stage
    • Most rapid growth
    • Third month until term
    • 6g to 3500g
  106. Maturation
    Stabilization of cell number and size (occurs after tissues and organs are fully developed later in life)
  107. Small for Gestational Age
    Newborns with a weight < 10th percentile for gestational age
  108. Disproportionately SGA
    Newborns that weigh <10th percentile for weight for gestational age and have normal head circumference and length
  109. Proportionately SGA
    Newborn’s weight, height and head circumference are all <10th percentile
  110. Large for Gestational Age
    Newborns with weights > 90th percentile for gestational age
  111. Appropriate for Gestational Age
    Weight, length and head circumference are between the 10th and 90th percentiles
  112. Ponderal Index
    • Used to assess the appropriateness of newborn size:
    • -Weight in grams/cm3 x 1000 
    • Values between 23 and 25 are considered normal weight for length
  113. Fetal Origins-Hypothesis of Later Disease Risk
    • Theory that exposures to adverse nutritional & other conditions during critical or sensitive periods of growth & development can permanently affect body structures & functions
    • Changes may predispose individuals to CVD, type 2 diabetes, hypertension, & other disorders in later life
  114. Fetal-Origins Hypothesis Reasons
    • Influenced by genes and environment
    • Developmental plasticity
    • Concept that the development can be modified by particular environmental conditions experienced by a fetus or infant
    • Epigenetic mechanisms-change gene function without changing DNA sequence
  115. Prepregnancy weight/ht and pregnancy weight gain
    2 Most Important Factors Determining Birthweight
  116. Pregnancy BMI
    • Underweight: 28-40 lbs
    • Normal weight: 25-35 lbs
    • Overweight: 15-25 lbs
    • Obese: 11-20 lbs
  117. Too Little Weight Gain
    • Gains of < 0.5 lb (0.25 kg)/week in the 2nd trimester and 0.75 lbs (0.37 kg) in the 3rd trimester in under- or normal weight women increases risk for preterm and SGA infants
    • Gains of < 0.5 lbs in overwt/obese in the 3rd trimester increases risks
  118. Too Much Weight Gain
    Third trimester gains greater than 1.5 lbs/week (0.7 kg) in normal and obese women adds little to birthweight and may increase postpartum weight retention
  119. Energy Costs of Pregnancy
    • Increase in basal metabolism
    • Changes in physical activity
    • Dietary induced thermogenesis
    • Cumulative costs is estimated to be 85,000 kcal
    • 300 additional cal/d; (340 2nd trimester to 452 in 3rd trimester)
  120. Protein Needs for Pregnant Women
    • Adaptive responses in nitrogen metabolism occur to retain more nitrogen for protein synthesis for the mother and fetus
    • Requirement is based on nonpregnant woman plus the needed amounts for growth during gestation (~ 925 gms)
    • Add 25 grams/day for women ≥14 years of age (1.1 grams/kg/day)
  121. Fat Needs for Pregnant Women
    • Need about 33% fat calories in diet
    • Linoleic acid (18:2, n-6) - primarily vegetable oils; synthesizes arachidonic acid (20:4 n-6)
    • Linolenic acid (18:2 n-3) - some oils, greens; converted to docosahexaenoic acid (DHA; 20:5 n-3), a fatty acid found in cold water fish
    • DHA is important for retinal development; incorporated into retina at a high rate late in pregnancy and first 6 months following delivery
  122. EPA & DHA Needs for Pregnant Women
    • EPA dilates blood vessels, reduces blood clotting and reduces inflammation
    • DHA is an structural component of phospholipids in cell membranes of the CNS, including the retina
    • Infants from pregnant women who consume adequate amounts may have health benefits
    • Recommend 250 mg/day; 500 mg is safe
    • Consume no more than 12 ounces of fish per week 
    • Eat no more than 6 ounces of albacore tuna per week
    • Most pregnant women are getting EPA and DHA from supplements, which are safe
  123. Water Needs for Pregnant Women
    • High needs during pregnancy
    • Increased significantly with exercise
    • Need approximately nine cups of H20/day
    • Monitor urine color
  124. Folate Needs for Pregnant Women
    • A methyl group donor and enzyme cofactor in metabolic reactions involved in the synthesis of DNA
    • Deficiency of folate impairs these processes, leading to abnormal cell division and tissue formation
    • Consume 600 mg /day of Dietary Folate Equivalents (DFE), and include 400 mg from supplements or fortified foods and 200 mg from fruits and vegetables (these foods provide ~40 mcg of folate per serving)
    • One DFE = 1 mg food folate, 0.6 mg folic acid fortified in foods or supplement taken with foods and 0.5 mg folic acid supplement taken on an empty stomach
  125. Folate Assessment
    • Use RBC folate vs serum folate to assess status; measures long-term rather than short-term intakes
    • RBC values > 300 ng/ml or 680 nmol/L are associated with low risks
    • Achieved by intakes of 400 mcg/day of folic acid; hard to achieve by diet alone
  126. Vitamin A Needs for Pregnant Women
    Recommendation is to consume no more than 5000 IU as retinol from supplements
  127. Vitamin D Needs for Pregnant Women
    • Deficiency during pregnancy poses a risk for the neonate and infant
    • The fetus may be abnormal
    • The neonate and infant may develop rickets
    • Linked to functioning of the immune system and inflammation
    • Policy by the WIC program to increase breastfeeding may have contributed to increased cases of rickets
    • The recommendation for supplementation to infants of exclusively breastfed infants is now higher (400 IU)
  128. Vitamin D & Pregnancy
    • RDA is 15mg/d (600 IU/d; IOM 2010)
    • Poor intakes; fortified foods
    • Limited sun exposure and use of sun block
    • Dark skin
    • Poor maternal vitamin D status may linked to long-term human health conditions
  129. Iron Deficiency during Pregnancy
    • In the first trimester significantly increases the risk of low-birth weight and pre-term infants
    • In the 3rd trimester significantly increases the risk of low intelligence scores, language problems
  130. Iron Needs for Pregnant Women
    • Need iron for red blood cell synthesis
    • -To carry oxygen to the fetus
    • -A lot is transferred to the fetus in the 3rd trimester
    • For fetus and placenta: 300mg
    • Blood lost (delivery): 250mg
    • For increase in RBC: 450mg
  131. Iron Absorption
    • Increases by the 30th week of gestation
    • Increases with lower levels of iron supplements
    • Increases when supplements are given by itself (<5% vs >10%)
    • Increases in women with poor iron status
  132. Calcium Needs for Pregnant Women
    • Needed for fetal skeletal mineralization
    • Calcium absorption and bone remodeling increase during pregnancy
    • May be beneficial with respect to hypertensive disorders of pregnancy, especially in those with low intakes (<500 mg/day)
    • RDA - 1300 mg/day for 14-18 yrs and 1000 for 19-50 yrs
    • Needs can be met by drinking 4 c milk/day or 2 c fortified OJ + 2 cup milk/day
  133. Zinc Deficiency during Pregnancy
    • Teratogenic
    • Does not mobilize zinc from bone
    • Associated with an increased malformation rate and other poor pregnancy outcomes
    • Low serum and leukocyte zinc is associated with lower birth weight babies and pregnancy complications
  134. Zinc Needs for Pregnant Women
    • Zinc supplementation trials are mixed in response to pregnancy outcomes
    • Most favorable results are seen in women with low serum zinc values
    • The RDA for zinc during pregnancy is 11 mg
  135. Caffeine
    • Increases heart rate, acts as a diuretic, stimulates the CNS
    • Easily passes through the placenta to the fetus
    • Lingers in the fetus longer because the fetus excretes it more slowly
  136. Alcohol
    • There is no clearly defined safe level of alcohol intake during pregnancy; therefore it is strongly advised that pregnant women do not drink
    • “Fetal Alcohol Spectrum” is used to describe the harmful effects of gestational alcohol exposure
    • Alcohol easily crosses the placenta and the fetus does not have adequate enzymes to degrade the alcohol
  137. Fetal Alcohol Syndrome
    • Due to alcohol exposure during critical periods of fetal development
    • Approximately 40% of infants born to women who drink heavily (≥ 4 drinks/ day) will develop it
    • Permanent alterations in facial features
    • Poor coordination, short attention span, behavioral problems, growth retardation
  138. Symptoms of Fetal Alcohol Syndrome
    • Show impaired rates of learning
    • Experience poor memory
    • Have trouble generalizing behaviors and information
    • Act impulsively
    • Exhibit reduced attention span or is distractible
    • Display fearlessness and are unresponsive to verbal cautions
  139. Fetal Alcohol Effects
    • More subtle features
    • Have mental and behavioral features, but not the malformations
  140. Pica
    • Compulsive food behavior or craving during pregnancy due to changes in taste and smell
    • Eat clay and dirt (geophagia), laundry starch (amylophagia), ice (pagophagia)
    • More likely to be iron deficient, have gestational diabetes, lead poisoning, intestinal obstruction, and parasitic infestation of the GI tract
    • Substitute for food = poor nutrition
  141. Cigarette Smoking
    • Definitely causes low birth weight babies
    • Most likely due to poor transfer of oxygen and nutrients across the placenta
    • Negative effects on fetal growth are greater in older women
    • Doubled the risk for Sudden-Infant Death Syndrome (SIDS)
    • Cessation should be one of the highest priorities in preconceptual care
  142. Health Problems during Pregnancy
    • Nausea & vomiting
    • Hyperemesis gravidarium
    • Heartburn
    • Constipation
    • Hypertensive Disorders of Pregnancy
    • Diabetes Mellitus
    • Phenylketoneuria
  143. Hyperemesis gravidarium
    • Small percent (1-2%) have a more serious disorder that requires IV fluid and electrolyte replacement
    • These women may have trouble gaining appropriate weight and may be at risk for nutritional deficiencies and dehydration
  144. Hypertensive Disorders
    • ~10% of all pregnancies; 2nd leading cause of maternal mortality in the US
    • Pre-existing chronic hypertension 
    • Gestational hypertension
    • Pre-eclampsia 
    • Eclampsia
  145. Pre-Exisiting Chronic Hypertension
    • Blood pressure 140/90 before pregnancy or before 20 weeks gestation (1-5%)
    • Continue medical therapy; try to minimize drug use
    • Avoid excessive weight gain and use moderate sodium
  146. Gestational Hypertension
    Abnormal rise in blood pressure after the 20th week of gestation
  147. Pre-Eclampsia
    • Hypertension with proteinuria and/or edema after 20 weeks gestation
    • Hypertension: 140/90 mmHg or an increase of 30 mmHg in systolic and 15 mmHg diastolic over normal; 160/110 in severe cases
    • Proteinuria: urinary excretion of 0.3 grams or more in 24 urine
    • collection; 5 gm/24 hr in severe cases
    • Edema
  148. Eclampsia
    More advanced; life threatening situation evidenced by seizures and coma
  149. Signs & Symptoms of Pre-Eclampsia
    • Hypertension
    • Insulin resistance
    • Increased urinary protein
    • Decreased plasma volume expansion
    • Persistent headaches
    • Sensitivity of eyes to bright light
    • Blurred vision
    • Abdominal pain
  150. Nutritional Management
    • 1000-2000 mg calcium
    • Adequate vitamin D status
    • Use of multivitamin-mineral supplement
    • Five or more servings of fruits and vegetables
    • Consume foods based on MyPlate
    • Moderate exercise, unless contraindicated
    • -Some women are on bedrest
    • Weight gain recommendations based on prepregnancy weight
  151. Gestational Diabetes
    Develops during pregnancy; ~ 7.5% of pregnant women
  152. Type I Diabetes
    • Insulin-dependent diabetes mellitus (IDDM)
    • Insulin deficient
  153. Type II Diabetes
    • Insulin resistant-usually doesn’t require insulin
    • Requires insulin during pregnancy
  154. Diabetes in Pregnancy
    • Early in pregnancy insulin requirements are lower because of increased glucose going to fetus and nausea/vomiting that sometimes occurs
    • Later in pregnancy, insulin requirements are increased 65 70% (because of placental hormones) and sensitivity is diminished; ketosis can occur
  155. Ketosis
    • The body relies on fat
    • Fatty acid is oxidized and acetyl coA is being generated so much, and it builds up from fatty acid synthesis that it  leaves ketones in the body
    • Ketones are used for energy, but if you generate too much, it changes acid/base balance
  156. Problems for Pregnant Women with Gestational Diabetes
    • C-section delivery
    • Increased risk of preeclampsia
    • Increased risk of type II diabetes, high blood pressure and obesity later in life
    • Increased risk of gestational diabetes in subsequent pregnancy
  157. Gestational Diabetes: Problems for Baby
    • Stillbirth
    • Spontaneous abortion
    • Macrosomia (> 10 lbs or > 4500 g)
    • Neonatal hypoglycemia
    • Increased risk of type II diabetes, high blood pressure and obesity later in life
  158. Blood Glucose Screening
    • Should be conducted at the initial visit if the woman is high risk
    • Test at 24-28 weeks gestation
    • Use a 50 gm 1-hour test; if the blood glucose value is >130 mg/100 ml, a complete 3-hour glucose tolerance test (GTT) should be conducted
  159. Glucose Tolerance Test
    • If two or more values are higher, then gestational diabetes is the diagnosis
    • Fasting- >95/100
    • 1 hr- >180/100
    • 2 hr- >155/100
    • 3 hr- >140/100
  160. Goal of Pregnant Women with Diabetes
    The critical objective is to maintain good glycemic control before and during pregnancy; if this is achieved there will be minimal risks, similar to the non-diabetic pregnant women
  161. Pregnant & Diabetes: Nutrition Therapy
    • Energy needs – 20-40 kcal/kg bw depending on weight status
    • Carbohydrate 40 - 50% of total calories (focus on complex carbohydrates and limit simple sugars)
    • Fat 30 - 40% of total calories (limit saturated fat)
    • Protein 20% of total calories
    • Regular meals and snacks should be distributed throughout the day to maintain blood glucose levels
    • Use ADA Diabetic Exchange Lists
    • Develop an individualized diet and exercise plan; regularly assess
    • Monitor weight gain
    • Help interpret blood glucose and urinary ketone values
  162. Breastfeeding Benefits for Mother
    • Increases oxytocin levels:
    • -Stimulates contraction of the uterus
    • -Minimizes postpartum blood loss
    • -Brings uterus back to pre-pregnancy size
    • Delays fertility (doesn’t prevent)
    • Positive for countries with high birthrates to promote breastfeeding
    • Promotes self-confidence and bonding with mother and infant
    • Lowers risk for breast and ovarian cancer, if start nursing at a younger age and for longer duration
    • Data on weight loss are mixed
  163. Breastfeeding Benefits for Infant
    • Nutritionally superior to human milk substitutes (HMS); optimal milk for the infant
    • No need for dilution; same ionic concentration as plasma
    • Lower protein content; whey protein
    • Essential fatty acids (DHA) and bioavailable minerals
    • Protect against infection; contains T- and B-lymphocytes, immunoglobins, neutrophils, macrophages, epithelial cells
    • Reduced acute and chronic illness in the infant
  164. Breast Development
    • Puberty- a system of ducts, lobes, and alveoli develop
    • Stage 2- stimulated by insulin growth factor I and estrogen
    • During pregnancy- stimulated by prolactin and estrogen
  165. Mammary Gland
    • Lobe -> lobule -> alveoli -> alveolus -> secretory cells
    • Alveoli are the functional units and each is composed of secretory cells with a duct in the center
    • Myoepithelial cells, that line the alveoli, contract during letdown causing milk ejection into lactiferous ducts
    • Milk is stored in lactiferous sinuses
  166. Lactation: Estrogen
    • Ductal growth
    • Mammary gland diffferentiation with menstruation
  167. Lactation: Progesterone
    • Alveolar development
    • After onset of menses and during pregnancy
  168. Lactation: Prolactin
    • Alveolar development and milk production
    • Pregnancy and breastfeeding ( from 3rd trimester to weaning)
    • Steadily rising during pregnancy
    • Released in response to suckling, stress, sleep, & sexual intercourse
  169. Lactation: Oxytocin
    • Letdown; ejection of milk from myopithelial cells
    • From the onset of milk secretion to weaning
    • Tingling of the breast may occur corresponding to contractions in milk duct
    • Causes uterus to contract, seal blood vessels, and shrink in size
  170. Hormonal Changes During Lactation
    • Estrogen and progesterone remain low
    • Prolactin remains high
    • Oxytocin increases depending on if there's stimulation for breastfeeding
  171. Prolactin Response
    • 48 hours after:
    • -Prolactin increases in normal women after 30 minutes
    • -Prolactin decreases in overweight women after 30 minutes
    • 7 days after:
    • -Prolactin still increases in normal women
    • -Prolactin increases in overweight women after 30 minutes
  172. Yes, because fat composition can pass through
    The diet of the mom affects her breastmilk composition?
  173. No
    If a woman breastfeeds for 6 months, does the baby need supplemental food?
  174. Lactogenesis: Stage I
    • Milk begins to form
    • Begins in last trimester until 2 days postpartum
  175. Lactogenesis: Stage II
    • l2-5 days postpartum until 10 days
    • Increased blood flow to mammary gland; significant changes in milk composition and quantity
    • Production of milk starts to increase
  176. Lactogenesis: Stage III
    • After day 10
    • Maintenance of milk supply
  177. Milk Production
    • 600 ml increasing to ~ 750 - 800 ml
    • Depends on infant weight, caloric density of milk, infant age, infant demand (more removed -> more produced)
    • Does not matter about breast size; more likely to affect milk storage
    • Feedback Inhibitor of Lactation (a protein), and nitric oxide, appear to influence milk production
  178. Letdown Reflex
    • Prolactin stimulates milk production and inhibits ovulation
    • Oxytocin stimulates milk ejection and promotes uterine contractions
    • Both are high during breastfeeding, but are negative on nutrients for bones
    • -Lose 5-6% of bone
    • Sucking stimulus -> triggers release of oxytocin -> causes milk ejection
    • Can be triggered by other factors:
    • -Baby cry
    • -Sexual arousal
    • -Thinking about nursing
  179. Colostrum
    • Birth to 1-3 days
    • Thick, yellowish and high in carotene
    • Higher protein content than mature milk (2.0 vs 1.1 g/100ml)
    • Lactoferrin is a primary protein-has antimicrobial activity
    • Higher in IgA (0.5g vs 0.1g/100ml)-antibody that provides protection in the gut mucosa
    • Lower in sugar and fat
    • Lower in calories (55 vs 67 kcal/100ml)
    • Higher is sodium, vitamin A
  180. Transitional Milk
    3-10 days
  181. Mature Milk
    • 10 days on
    • Fore milk
    • Hind milk
  182. Human Milk: Water
    • Major component in human milk
    • Isotonic with maternal plasma
  183. Human Milk: Energy
    • Calories may vary with fat, protein and carbohydrate composition
    • Lower in calories than human milk substitute (HMS)
  184. Human Milk: Lipids
    • Provide ½ the calories in human milk
    • Effect of maternal diet on fat composition
    • Fatty acid profile reflects dietary intake of mother
    • Very low fat diet with adequate CHO & protein, milk is higher in medium-chain fatty acids 
  185. Human Milk: DHA
    • Essential for retinal development
    • Associated with higher IQ scores
  186. Human Milk: Trans Fatty Acids
    Present in human milk from maternal diet
  187. Human Milk: Cholesterol
    • Higher in human milk than HMS
    • -Part of the membranes in the neural tissue to help develop brain
    • Early consumption of cholesterol through breast milk appears to be related to lower blood cholesterol levels later in life
  188. Human Milk: Protein
    • Total proteins are lower than in whole cow’s milk (0.32 vs. 0.98 g/oz)
    • Have antiviral & antimicrobial effects
    • Casein
    • Whey
    • Advantage to have lower protein
    • -Excess protein needs to get rid of the excess nitrogen
    • Non-protein nitrogen
    • ~20-25% nitrogen in human milk
    • -Used to make non-essential amino acids
  189. Casein
    • Main protein in mature human milk
    • Facilitates calcium absorption
  190. Whey
    • A soluble protein that precipitates by acid or enzyme-fluid after milk coagulates
    • Some mineral, hormone & vitamin binding proteins are part of it
  191. Milk Carbohydrates
    • Lactose
    • Oligosaccharides
  192. Human Milk: Lactose
    • Dominant carbohydrate
    • Enhances calcium absorption
  193. Human Milk: Oligosaccharides
    • A medium-length carbohydrate
    • Prevent binding of pathogenic microorganisms to gut, which prevents infection & diarrhea
  194. Human Milk: Vitamin E
    • Level linked to milk’s fat content
    • Level not adequate to meet needs of preterm infants
  195. Human Milk: Vitamin K
    • ~5% of breastfed infants at risk for deficiency based on clotting factors
    • Infants who did not receive injection at birth may be deficient
    • The gut microbes synthesize it
    • -Brand new gut so aren’t able to synthesize it
  196. Human Milk: Vitamin A
    • Content in colostrum is ~double that of mature milk
    • Yellow color from beta-carotene
  197. Human Milk: Vitamin D
    • 25-(OH)D
    • Content reflective of mother’s exposure to sun
    • You don’t measure the active metabolite because it has a really short half-life
    • 25 reflects how much sunlight you get and in your diet
    • Regulated by calcitonin, parathyroid hormone
  198. Nutritional Rickets
    • Caused by vitamin D deficiency and severe protein and energy (caloric) deficiency
    • Melanin in skin competes with 7-DHC for UV light, thus decreasing vitamin D synthesis 
    • Vitamin D content of human milk is low, however, among most breastfed infants, the combination of breast milk and sunlight exposure provides sufficient vitamin D 
  199. Nutritional Rickets Population
    • Occurs mostly in offspring from African-American women who breastfed for an average of 12.5 months
    • Growth failure was common as indicated by low height-weight percentiles
    • Skin synthesis of vitamin D is less per UV exposure in dark-skinned vs light skinned individuals; requires more UV exposure
  200. Lactating: Vitamin D Recommendation
    • Infants should receive 400 IU of vitamin D in the first few days after birth
    • The old requirement was 200 IU by 2 months of age 
  201. Human Milk: Water-Soluble Vitamins
    • Content reflective of mother’s diet
    • Vitamin most likely to be deficient is B6
  202. Human Milk: Vitamin B12 & Folate
    • Bound to whey proteins
    • Low B12 seen in women who:
    • -Are vegans or malnourished
    • -Have had gastric bypass 
  203. Human Milk: Minerals
    • Contribute to osmolality
    • Content related to growth of infant
    • Concentration decreases over 1st 4 months, except for magnesium
    • Bioavailability
    • Most have high bioavailability
    • Exclusively breastfed infants have very low risk of anemia despite low iron content of human milk
  204. Human Milk: Zinc
    Bound to protein & highly available
  205. Human Milk: Trace Minerals
    In general, they are not altered by mother’s diet, excepting fluoride
  206. Human vs Cow Milk
    • Protein is lower (9 g vs 35 g/liter)
    • Higher in vitamins A, E, C
    • Lower in calcium, phosphorus, sodium
    • Low in vitamin K and iron
    • Higher in immunoglobulins and linoleic acid
  207. Renal Solute Load
    Collective number and concentration of solute particles in solution, carried to the kidney for excretion in the urine, usually nitrogen and electrolytes (primarily sodium and potassium)
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